OncoBlog: Single-Payer, the Authors Respond

When two oncologists wrote an editorial to make a case for a single-payer healthcare system, the response was immediate, abundant, and passionate -- on both sides of the issue. One reader, Gary Jones, AA-C, of Case Western Reserve in Cleveland, wrote a point-by-point rebuttal of the editorial, which set off another round of verbal jousting among MedPage Today readers. In response to the rebuttal by Jones, the two oncologists, Ray E. Drasga, MD, of Chicago, and Lawrence Einhorn, MD, of Indiana University in Indianapolis, submitted their own point-by-point response, published here as a guest blog.

"We read the rebuttal by Mr. Jones and appreciate his time and effort to comment upon our article in Journal of Oncology Practice (JOP). Medical oncologists are particularly data-driven and make clinical decisions based upon evidence-based medicine. Initially, data becomes information which can then lead to a change in standard practice. However, sometimes data simply permits us to form opinions and write commentaries.

"We did not expect complete congruence among the readers of the JOP paper. We realized the conclusions we reached would be contentious with a certain segment of the intended audience. H.L. Mencken once opined, 'For every complex problem there is an answer that is clear, simple, and wrong.' However, that does not mean we should avoid solutions for difficult issues, nor accept that the current status quo in healthcare is immutable. With these points in mind, we would like to respond to the points [in boldface below] that were raised by Mr. Jones."

1. Overhead costs for Medicare and Medicaid are higher than those in the private sector. Calculating the overhead costs based on the Medicare trustees' report rather than using Zycher's methodology dramatically changes per-capita spending. For example in 2005, Medicare's per-capita spending was $144 compared with $680 in the private sector. Medicare's overhead of 1.4% includes all types of nonmedical spending by the Centers for Medicare and Medicaid Services, as well as other federal agencies, such as the IRS, and is based on data contained in the latest report of the Medicare trustees. Alternative estimates aren't credible and have been refuted elsewhere. Under the Affordable Care Act, insurers are allowed overhead and profits of 15% of premiums, or 10-fold Medicare's.

2. Data on bankruptcies related to healthcare costs are inaccurate or misleading. The high proportion (three-fourths) of people with coverage at the onset of illness or injury demonstrates how widespread the problem of under-insurance is. This is particularly the case for cancer patients, who face high deductibles, copays, and high medication costs even with coverage. When you add the under-insured to the uninsured, about 80 million Americans would be financially devastated by a serious illness. In a recent study from the CDC, one-fourth of Americans reported having problems paying medical bills. We have a national problem and need a national solution. Medical bankruptcies in Canada are unheard of.

3. Outcomes with Medicare and Medicaid should be compared with those of private-sector payers, not with the underinsured or uninsured. Medicare is better than private insurance at controlling costs, and beneficiaries are more satisfied with their coverage. Furthermore, studies show that the private Medicare Advantage plans that participate in the Medicare program raise Medicare's costs by 14% per beneficiary -- over $34 billion annually.

4. Using the existing publicly funded system as the foundation for a single-payer system makes little sense. Instead of building on the existing system run by private insurers, who consider every dollar spent on healthcare to be a "loss," we propose the U.S. adopt a nonprofit national health insurance program, like an improved Medicare for all. We propose to stop using public funds to enrich the drug and insurance companies. We are already paying for comprehensive coverage for everyone, but we aren't getting it.

5. Government-mandated cost-containment strategies will not work. Effective cost-containment strategies are well known and include implementing global budgets for hospitals, negotiated fees with providers, and bulk-purchasing of drugs and medical supplies. Although it's better at controlling costs than private insurers, if the U.S. Medicare program was as good at controlling costs as Canada's is for care of the elderly, the U.S. would have saved over $2 trillion since 1980, when our health systems diverged.

6. Increased access to care does not assure improved quality of care or outcomes. The U.S. ranks 19th out of 19 high-income countries in preventing deaths amenable to medical care, and while we are improving slightly, other countries are improving faster, so we are falling further behind.

7. Reverse the trend toward government-funded healthcare and empower patients by increasing choices. People don't want to be free to choose between two or three or 300 overpriced, defective insurance products. They want to choose their doctors and know they will receive medically necessary healthcare if they become ill or injured. Private insurance with its "skinny" networks means that people have a limited choice of oncologists and may have to change doctors annually.

8. Physician income will decrease as government-funded healthcare increases. Once you factor in lower malpractice costs in Canada and their much lower overhead to run a practice, the difference in earnings isn't that great. Besides, with our much greater level of health spending (twice Canada's) we can afford to continue to pay physicians well.

OncoBlog is a blog by the MedPage Today staff for readers with an interest in oncology. This post comes from guest bloggers Ray Drasga, MD, and Lawrence Einhorn, MD.

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